Provider Demographics
NPI:1467539569
Name:MANISTEE ORTHOPAEDICS
Entity Type:Organization
Organization Name:MANISTEE ORTHOPAEDICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLER
Authorized Official - Prefix:MS
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:BAUMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-398-1752
Mailing Address - Street 1:1293 E PARKDALE AVE
Mailing Address - Street 2:SUITE 2200
Mailing Address - City:MANISTEE
Mailing Address - State:MI
Mailing Address - Zip Code:49660-8904
Mailing Address - Country:US
Mailing Address - Phone:231-398-1750
Mailing Address - Fax:231-398-1751
Practice Address - Street 1:1293 E PARKDALE AVE
Practice Address - Street 2:SUITE 2200
Practice Address - City:MANISTEE
Practice Address - State:MI
Practice Address - Zip Code:49660-8904
Practice Address - Country:US
Practice Address - Phone:231-398-1750
Practice Address - Fax:231-398-1751
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301046367207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2005155171OtherBCBS
MI4743229Medicaid
MI2005155171OtherBCBS